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com Ann Cardiothorac Surg 2013;2(4):427-430

Keynote Lecture Series
Current status of arterial grafts for coronary artery bypass
grafting
David P. Taggart
Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK
Corresponding to: Professor David P. Taggart, MD (Hons), PhD, FRCS. Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital,
Oxford, OX3 9DU, UK. Email: david.taggart@orh.nhs.uk.
For over a decade there has been accumulating evidence that the use of more than a single arterial graft during
coronary artery bypass grafting can improve clinical outcomes. However the vast majority of patients in most
developed countries still only receive a single arterial conduit even in the presence of multivessel coronary
artery disease. This review summarizes the current evidence for the use of a second internal mammary
artery and/or radial artery graft. While in comparison to vein grafts the superior patency of internal
mammary artery grafts is well established, there now exists strong and consistent evidence of the superior
patency of radial arteries over the longer term. Likewise, there is a rapidly growing body of evidence that
the superior patency of both these arteries in comparison to vein grafts translates into improved clinical
outcomes.
Keywords: Coronary artery bypass grafting (CABG); internal mammary artery (IMA); radial artery graft
Submitted Jul 11, 2013. Accepted for publication Jul 25, 2013.
doi: 10.3978/j.issn.2225-319X.2013.07.21
Scan to your mobile device or view this article at: http://www.annalscts.com/article/view/2403/3269
Arterial revascularisation for coronary artery bypass
grafting
Almost three decades ago Loop and colleagues published
their landmark study describing that the routine use of an
internal mammary artery (IMA) graft, rather than
exclusive use of saphenous vein graft (SVG), during
coronary artery bypass grafting (CABG) led to improved
survival and was accompanied by a reduction in the
subsequent incidence of myocardial infarct, recurrent
angina and the need for repeat intervention (1). Although
several other surgical groups were also simultaneously
promoting the use of an IMA for CABG, it was the
strength of the survival and other clinical benefits of an
IMA, identified in the Cleveland Clinic publication, which
led to a widespread increase in its use throughout the world.
Since then a considerable body of evidence has emerged
confirming the benefits of the IMA graft, much of which now
extends into the second and third decades of follow-up (2,3).
The improved benefits of an IMA graft over exclusive
use of SVGs is almost certainly due to its markedly
superior long-term patency. Structurally, the IMA has a
discontinuous internal elastic lamina and a relatively thin
media with multiple elastic laminae and absence of a
significant muscular component, which explains a reduced
tendency for spasm and the development of atherosclerosis.
In contrast, the SVG has a thinner, more permeable
endothelium and a thinner, less elastic and more muscular
media. Physiologically, the IMA has significantly increased
rates of nitric oxide production in both basal and
stimulated states. As a consequence of these structural and
functional differences the SVG is far more susceptible to
thrombosis and the development of intimal hyperplasia (a
precursor to atherosclerosis) in response to endothelial
damage and lipid metabolism. Consequently, while the
IMA has patency rates in the region of 90-95% ten to
fifteen years after CABG, SVG failure occurs in
approximately 50% of grafts five to ten years after surgery
with significant atheroma in most of the remaining grafts
(4,5).
More than a decade ago several groups were already
reporting the additional survival benefit of a second IMA
over a single IMA. Our group published a systematic
428 Taggart. Current status of arterial grafts for CABG
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review of these studies in the Lancet in 2001 (6) and
reported that in a comparison of over 11,000 patients with
a single IMA and 4,500 with bilateral IMA grafts, that the
hazard ratio for mortality was 0.81 with bilateral IMA grafting.
This translated into a need-to-treat value of 13-16 patients
to have one extra survivor. However the obvious caution is
that this was not a randomized trial, and that although the
patients were well matched for important baseline
characteristics including age, gender, LV function and
diabetes, which by themselves can predict likely longevity
independent of the presence of knowledge of coronary
artery disease, there is still the potential for bias by other
known and unknown confounding factors. Since then,
numerous other studies have also supported the additional
survival benefit with a second IMA graft (7-12).
Despite such evidence, the stark fact is that only 5-10% of
patients in most developed countries actually receive
bilateral IMA grafts. The most frequently cited reasons for
not routinely using both IMA grafts are a potential
increase in perioperative mortality, morbidity, increased
duration of operation and an increased risk of sternal
wound problems (13). The only published randomized trial
to address these issues is the Arterial Revascularisation Trial
(ART) (14). This is an ongoing trial of 3,102 patients
randomized to single or bilateral IMA grafts and
conducted in 28 centers in seven countries. While enrolment
has been completed and a one-year interim analysis
published (15), the primary outcome of ART is 10-year
survival, with final results expected in 2018. The one-year
outcomes showed that the application of a second IMA
added around 23 minutes to the duration of surgery but
made no difference to the incidence of death, stroke or
myocardial infarction, at both 30 days and one year (all
being around 2% at one year).
Importantly there was, however, a statistically significant
increase in the incidence of sternal wound reconstruction
from 0.6% in the single IMA group to 1.9% in the bilateral
IMA group, which translated into a need-to-harm number
of 78 patients (15). However, it must be considered that
almost half of the patients requiring sternal wound
reconstruction had diabetes, in comparison to around one-
quarter of patients in the overall trial. The presence of
diabetes, coronary obstructive pulmonary disease, obesity
and advanced age are well-recognized risk factors for
impaired sternal wound healing and consequently the use
of both IMA should be used cautiously in such patients and
particularly when more than one risk factor is present.
Furthermore there is strong evidence that using a skeletonized
technique to harvest IMA grafts, rather than a pedicled
technique, results in better preservation of blood supply to
the chest wall and a reduced incidence of sternal wound
problems (16).
The radial artery
The radial artery (RA) was first used by Carpentier and
colleagues in 1974 (17) but subsequently abandoned due to
high failure rates (18). Structurally the RA has a thin
continuous intima of endothelial cells, a single internal
elastic lamina and a relatively thick media of tightly-packed
smooth muscle cells, which predisposes to spasm, occlusion
and thrombosis (19). Furthermore, histopathological
comparison of proximal and distal RA segments demonstrate
significantly reduced luminal diameter and increased
intimal hyperplasia distally (20). Although the incidence of
atherosclerosis is greater in the RA compared to the IMA (5.3%
vs. 0.7%), this is still very low and demonstrates overall
resistance to atherosclerosis (19). Even so, the RA still has a
relatively low rate of atherosclerosis at around 6% (21). In
1992 Acar and colleagues re-popularized the use of the RA
when they reported a series of 56 radial artery grafts with 100%
patency (22).
Patency of RA vs. SVG over the short and longterm
Four systematic reviews have addressed the issue of graft
patency comparing the RA and SVG. A 2010 meta-analysis of
five RCTs showed equivalent RA (14.1%) and SVG (14.6%)
failure at a mean follow-up of 22 months (23). In contrast,
Athanasiou and colleagues compared patency rates of 3678 RA
and 7506 SVG from thirty-five studies, at short- (less than one
year), medium- (one to five years) and long- (greater than five
years) term follow-up (24). The analysis showed no significant
difference in the short-term [odds ratio (OR) 1.04] but
significantly better RA patency over the medium- (OR 2.06)
and long- (OR 2.28) term. Similarly, Hu and colleagues
reported in a meta-analysis comparing occlusion rates of RA
and SVG to non-LAD target vessels, at mean follow-up of 56
(range 12-74) months, of a significantly reduced risk of
occlusion of RA grafts (relative risk 0.507) (25). Likewise,
Cao and colleagues compared angiographic outcomes in
859 RA and 849 SVG from five RCTs at one- and fouryears
(26). At one-year there was no significant difference in
occlusion between RA and SVG grafts (9.1% vs. 12.7%, OR
0.71) but a far higher incidence of string sign in the RA grafts
(7.4% vs. 1.0%, OR 7.97). However at four years RA occlusion
Annals of cardiothoracic surgery, Vol 2, No 4 July 2013 429
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was significantly lower (2.7% vs. 14.7%, OR 0.17) with no
significant difference in string sign (2.7% vs. 0%, OR 3.55).
Again, while there was no difference in perfect patency
reported at one-year (79.2% vs. 82.5%, OR 0.79), RA grafts
had significantly higher perfect patency at four years (89.9% vs.
63.1%, OR 5.19).
It is now very well established through numerous studies
that the severity of stenosis in the native coronary artery is
critical to both the short- and long-term patency of the RA,
because of the potentially negative effects of competitive flow
when the stenosis is below 70-80% (27,28). Furthermore it
needs to be recognized that visual estimates of the severity of
coronary stenoses are frequently very inaccurate when
compared to more objective measurements such as fractional
flow reserve. Finally, the competitive flow that will remain will
be much greater in a 4 mm vessel with a 70% stenosis than a 2
mm vessel with an equivalent stenosis.
Clinical outcomes RA vs. SVG
Overall, only one RCT comparing RA and SVG has
demonstrated superior clinical outcomes with RA grafts. RAPS
reported more death from cardiac causes, non-fatal MI and
repeat revascularization with SVG rather than RA grafts at late
outcome (29). Goldman et al. showed no difference in death,
MI, stroke and repeat revascularization between RA and LSV
grafts at one-year (30) while the RSVP trial showed no
difference in mortality at five years in an older population
(mean age >70 years) (31). In contrast, several larger
propensity matched registries have reported survival benefits
with RA rather than SVG at three, six and fourteen years
follow-up and particularly in diabetic patients (32-34).
In summary, current literature suggests that there is no
difference in functional patency between RA and LSV grafts
over the first year. However, there is strong and accumulating
evidence for higher mid- and long-term patency rates for the
RA in comparison to SVG, due to an ongoing attrition of
vein grafts over the long-term. There is now also growing
evidence that the superior long-term patency of the RA is
translating into substantial improvements in clinical
outcomes.
Acknowledgements
Disclosure: The author declares no conflict of interest.
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Cite this article as: Taggart DP. Current status of arterial grafts
for coronary artery bypass grafting. Ann Cardiothorac Surg
2013;2(4):427-430. doi: 10.3978/j.issn.2225-319X.2013.07.21